Jones Criteria for Rheumatic Carditis and Treatment
The 2015 revised Jones criteria from the American Heart Association are the gold standard for diagnosing acute rheumatic fever, with subclinical carditis detected by echocardiography now considered a major criterion alongside clinical carditis. 1, 2
Diagnostic Criteria for Acute Rheumatic Fever
Evidence of Preceding Group A Streptococcal Infection (Required)
- Positive throat culture or rapid antigen test for GAS
- Elevated or rising anti-streptolysin O (ASO) titer
Major Criteria
- Carditis (clinical or subclinical detected by echocardiography)
- Arthritis (polyarthritis in low-risk populations; monoarthritis or polyarthralgia in moderate/high-risk populations)
- Chorea
- Erythema marginatum
- Subcutaneous nodules
Minor Criteria
For low-risk populations:
- Polyarthralgia
- Fever (≥38.5°C)
- ESR ≥60 mm/h and/or CRP ≥3.0 mg/dL
- Prolonged PR interval on ECG
For moderate/high-risk populations:
- Monoarthralgia
- Fever (≥38°C)
- ESR ≥30 mm/h and/or CRP ≥3.0 mg/dL
- Prolonged PR interval on ECG
Diagnostic Requirements
- Initial ARF diagnosis: 2 major criteria OR 1 major + 2 minor criteria PLUS evidence of preceding GAS infection 1, 2
- Recurrent ARF with established RHD: 2 major OR 1 major + 2 minor OR 3 minor criteria PLUS evidence of preceding GAS infection 2
Echocardiographic Criteria for Rheumatic Carditis
- Doppler echocardiography is essential for detecting clinical or subclinical carditis 2
- Pathological mitral regurgitation is the most common finding
- Aortic regurgitation may also be present (isolated aortic regurgitation is rare)
- Key features to differentiate from physiological regurgitation:
- Jet length ≥2 cm
- Velocity >3.0 m/s
- Seen in at least two views
- Holosystolic for mitral regurgitation
Treatment of Rheumatic Carditis
Eradication of GAS infection:
- Penicillin V orally for 10 days OR
- Benzathine penicillin G as a single intramuscular injection
- For penicillin-allergic patients: oral macrolide/azalide 2
Anti-inflammatory therapy for carditis:
Secondary prophylaxis:
- Benzathine penicillin G 1.2 million units IM every 3-4 weeks
- For penicillin-allergic patients: oral sulfadiazine or macrolide/azalide 2
- Duration depends on presence of carditis:
- No carditis: minimum 5 years or until age 21, whichever is longer
- Carditis without residual heart disease: 10 years or until age 21, whichever is longer
- Carditis with residual heart disease: at least 10 years since last episode and at least until age 40, sometimes lifelong
Monitoring:
- Serial ESR and CRP measurements to track inflammation
- Repeat echocardiography to assess valvular changes
- Regular clinical follow-up
Important Clinical Considerations
- Risk stratification is crucial - different diagnostic thresholds apply to low-risk versus moderate/high-risk populations 1, 2
- Joint manifestations can only be considered in either major or minor categories, not both 1
- In "possible" rheumatic fever cases where criteria are not fully met but clinical suspicion is high, consider 12 months of secondary prophylaxis followed by reevaluation 1
- Differential diagnosis for carditis includes congenital valve abnormalities, infective endocarditis, and mitral valve prolapse 1
- Rheumatic mitral valve prolapse differs from Barlow syndrome - only the coapting portion of the anterior mitral valve leaflet tip prolapses 1
Common Pitfalls to Avoid
- Misinterpreting elevated ASO titers as indicating acute infection rather than recent past infection
- Failing to use echocardiography to detect subclinical carditis
- Inadequate prophylaxis regimens increasing risk of recurrences
- Overdiagnosis in low-risk populations without proper evidence of preceding GAS infection
- Confusing physiological valve regurgitation with pathological findings on echocardiography